Acknowledgements Thanks to Dr. Ross Brownson and faculty at - PDF document

Evidence ‐ Based Public Health: Supporting the New York State Prevention Agenda MODULE 1: INTRODUCTION AND OVERVIEW July 22, 2015 Barbara Dennison, MD Christopher Maylahn, MPH Acknowledgements  Thanks to Dr. Ross Brownson and faculty at Washington University in St. Louis School of Public Health  Funding support from the Robert Wood Johnson Foundation through Washington University in St. Louis and the National Association of Chronic Disease Directors 1

Colleagues  New York State Association of County Health Officials  New York State Department of Health  SAGE Colleges, School of Management  SUNY School of Public Health Overview  Ground rules / Course Objectives  Notebooks / Readings  Obesity, physical activity, nutrition, other examples  Background and Definitions  differences between EBM and EBPH  contrast types of evidence  selected definitions  overview of tools/processes  challenges and barriers 2

Ground Rules  Attendance  Please leave cell phones, beepers on stun  Active Participation is Sought  All questions are welcome  No Tests Why is this course important? Understand the challenges in applying evidence-based methods in public health practice 3

“ . . . If we did not respect the evidence, we would have very little leverage in our quest for the truth.” Carl Sagan “Public health workers… deserve to get somewhere by design, not just by perseverance.” McKinlay and Marceau 4

“Getting a new idea adopted, even when it has obvious advantages, is often very difficult.” -- Everett Rogers, Diffusion of Innovations Decisions and relevance  Our commitment:  Improve health with limited resources  Generally, health problems are well defined  Our job:  Make a difference  Inaction is not an option  Sometimes difficult to identify best evidence to inform decision making 5

Decision-Making  Understanding a process  Finding evidence for decisions  Creating new evidence for decisions Our training framework… 6

Community Scientific Needs & Evidence Values Resources (Adapted and modified from Muir Gray) 7

Evidence-based public health is a process of:  Engaging stakeholders  Assessing what influences health, health behaviors and community health (literature, local needs, academic theory)  Developing programs based on assessment (science)  Evaluating process, impact, and outcome  Learning from our work and sharing it in ways that are accessible to ALL stakeholders Course Objectives MODULE 1: Introduction and Overview 1. Understand the basic concepts of evidence- based decision making. 2. Introduce some sources and types of evidence. 3. Describe several applications within public health practice that are based on strong evidence and several that are based on weak evidence. 4. Define some barriers to evidence-based decision making in public health settings. 8

Definitions and Background 1. What is Evidence-Based Public Health (EBPH)? 2. What are contrasts with evidence-based medicine (EBM)? 3. What are types of evidence? 4. What are useful tools and processes? What is “evidence”? 9

What is “evidence”?  Scientific literature in systematic reviews Objective  Scientific literature in one or more journal articles  Public health surveillance data  Program evaluations  Qualitative data  Community members  Other stakeholders  Media/marketing data  Word of mouth  Personal experience Subjective Like beauty, it’s in the eye of the beholder… How are decisions generally made in public health settings?  Anecdote or “gut feeling”  Media driven  Pressure from policy makers or administrators  History/inertia 10

 Expert opinions (e.g., academics)  Peer reviewed literature/systematic reviews  Cost minimization/Funding availability OR  Combined methods, based in sound science  How to make the best use of multiple sources of information?? What is EBPH? “... the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems, and appropriate use of behavioral science theory and program planning models.” Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-Based Public Health . New York: Oxford University Press; 2003 11

Some Key Characteristics of EBPH 1. Intervention approaches are developed based on the best possible scientific information. 2. Problem solving is multi-disciplinary. 3. Theory and systematic planning approaches are followed. Key Characteristics of EBPH (cont) 4. Sound evaluation principles are followed 5. Results are disseminated to others who need to know 12

Why do Programs/Policies Fail?  Choosing ineffective intervention approach  Selecting a potentially effective approach, but weak or incomplete implementation or “reach”  Conducting and inadequate evaluation that limits generalizability This course deals with… • Finding and using existing scientific evidence • Generating new evidence 13

Examples Based on Varying Degrees of Evidence?  California Proposition 99  smoking as key public health issue  effects of price increases  25 cent per pack increase in 1988  earmarked for tobacco control with strong media component  for 1988-93, doubling of rate of decline against background rate California adult smoking prevalence by region, 1990 Prevalence (%) <= 19.0 19.1 - 20.0 20.1 - 21.0 21.1 - 22.0 >= 22.1 14

California adult smoking prevalence by region, 1996 Siskiyou Modoc Shasta Trinity Lassen Humboldt Tehama Plumas Butte Mendocino Glenn Placer El Dorado Yolo Sacramento Tuolumne Contra Costa Mono San Francisco Mariposa San Mateo Merced Santa Cruz Madera Fresno Inyo Tulare Monterey Kings Prevalence (%) Kern <= 19.0 San Bernardino Santa Barbara Ventura 19.1 - 20.0 Los Angeles 20.1 - 21.0 Riverside 21.1 - 22.0 San Diego Imperial >= 22.1 California adult smoking prevalence by region, 1999 Prevalence (%) <= 19.0 19.1 - 20.0 20.1 - 21.0 21.1 - 22.0 >= 22.1 15

California adult smoking prevalence by region, 2002 Prevalence (%) <= 19.0 19.1 - 20.0 20.1 - 21.0 21.1 - 22.0 >= 22.1 Examples Based on Varying Degrees of Evidence?  Missouri TASP Program  MO child restraint law in 1984  After 8 years, compliance at 50%  TASP Program in 1992  Report license plates of children not properly restrained  In 1995, phone survey and observations showed low effectiveness 16

What is EBM?  Process has grown recently:  pathophysiology  cost-effectiveness  patient preferences  In large part, learning to read journals What is EBM? Sackett & Rosenberg: 1. Convert information needs into answerable questions. 2. Track down, with maximum efficiency, the best evidence with which to answer them (from the clinical examination, the diagnostic laboratory, the published literature, or other sources. 17

What is EBM? (cont) Sackett & Rosenberg: 3. Critically appraise that evidence performance for its validity (closeness to the truth) and usefulness (clinical applicability) 4. Apply the results of this appraisal in clinical practice 5. Evaluate performance Differences Between EBPH and EBM? 18

Differences Between EBM & EBPH Characteristics EBM EBPH Quality & volume quasi-experimental experimental studies of evidence studies Time from intervention to shorter interval longer interval outcome more formal – less formal – no Training certification required certification required Decision making individual group Types of Evidence Characteristic Type 1 Type 2 strength of relative effectiveness of Data preventable risk – public health programs disease relationship “something should be Action “this should be done” done” Quantity more less 19

More recently, type 3 evidence  Focuses on carrying out type 2 interventions  Implementation of the intervention  Issues of context  How the intervention is received from the target audience  Involves “ how something should be done” Rychetnik et al, 2004 In our research paradigms we may rely too heavily on randomized designs for community-based studies 20

“The best is the enemy of the good” - Voltaire The problem of randomized trials and parachutes…. The effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials…. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute. Smith and Pell, BMJ, 2004 21

When evidence is not enough  Cultural and geographical limitations  Largely Western-world phenomena  Evidence may be a luxury in some parts of the world  Bias in deciding what gets studied  Emerging health issues  Bioterrorism  Community-based & participatory approaches  May seem counter-intuitive to a strict evidence- based process Useful Tools and Processes  Systematic Reviews  e.g., Guidelines  Meta-Analysis  Economic Evaluation  Risk Assessment 22